Heme/Onc

Today I started the second week of adult outpatient Hematology/Oncology. I have a normal 9-5ish schedule and see patients in the clinic for visits regarding their cancer or blood disorders. I have seen many things from breast cancer to colon cancer, polycythemia to pancytopenia, anemias, leukemias, myelomas and lymphomas. I have spent some time in the hospital's infusion center with patients getting chemotherapy treatments and time with the pathologists looking at certain cancers under the microscope.

It has been an interesting rotation so far and I have enjoyed reviewing all these different disorders. However, I totally miss pediatrics. Adults just aren't as patient and fun to work with. Most adults don't expect you to make them laugh and giggle when you listen to their heart and lungs. A lot of them roll their eyes and ask when the actual doctor is going to be in. One very interesting thing about this rotation is seeing the various ways people deal with difficult diagnoses. I have seen patients who are so optimistic and so prepared to do whatever is necessary to defeat their disease. They are motivated and inspirational. I have seen other people who succumb to the disease and act defeated before they even have a complete diagnosis.

The physician is an integral part of these people's lives. I was present when a physician encouraged her patient to mend her broken family so she could have support during her illness. I have seen another physician lecture his patient about putting his life in order so he wouldn't lose his health benefits. These are very complex diseases and affect more than just the body - they affect the patient's entire life. It is exciting to realize how much trust and confidence these patients give to their doctor. It is humbling when patients open up and share the most intimate and private parts of their lives in order to fix their problems.

In other news - we finally got the snow we have been wishing for!! I love the snow and am so excited for Christmas. The snow makes it feel like Christmas is actually on it's way. This week is match week for me!! I should know where I will be doing residency by the end of this week. I'm so anxious it's all I can think about. Luckily I have a normal work schedule that allows me to get to the gym and deal with my anxiety that way.

Can't say no

I finally finished my crazy 3 month block of Pediatrics. One month in Texas, one in Dayton and one here in Toledo. It was exhausting and I worked some fairly long hours. I did managed to find time for fun on the days I was off. I knew I was going to need a break after those three months and I can't believe that that break is over! My two weeks of "flex" time allowed me to recuperate and get some things in order. However, I got roped into presenting an "interesting case" that I saw earlier this month. The Pt was only on my service for one day and decompensated quickly. He spent 2 days in the PICU (different service) and when I found out I would be presenting his case he was being transferred to the University of Michigan for some intense therapy. He survived (I thought he would die for sure) and now I have been busy trying to pull information from the PICU, Michigan and his Primary Care Provider. I finally pulled it all together this morning (I present tomorrow) and I no longer care how this presentation turns out for several reasons: He never had an actual diagnosis, I'm totally done with the rotation, the presentation will (should) not reflect on my evaluations, and the Military has already convened and my residency fate is already decided!! I should find out in 2 weeks where I will go. Needless to say, this presentation tomorrow should not affect me. It just has taken up a lot of my flex time to put together (grrrr). I need to learn how to say "no" to attendings!! I hope to get a good letter of recommendation from her - I don't need it, but maybe I can keep it in my journal or something.

Miller Emotions at it again...

I need to start off by saying the Miller emotion gene is hyperactive. If you have ever been around my family you will know that it is not uncommon for us to blubber through a hallmark hall of fame TV special, or cheer during the Olympics trying to not let the person sitting next to you notice the tears in the corners of your eyes, or become verklempt listening to Christmas music. I've done so much better and have gained much better control of my emotions than in years past. I rarely cry anymore, and I thought I had suppressed this Millerism. The other day it got the better of me and caused quite a scene.

I was on call and had been at work for 16 hours and had 14 hours still to survive. I was already tired and when I'm tired my emotions are harder to control. I was called to evaluate a 7-year-old who had just been sent to the hospital by her family doctor to be evaluted by a Heme/Onc doctor. I was to go obtain the child's story, do a physical exam and begin the admission orders for the doctor to come review. I walked into the room to find the cutest little family sitting together on the bed. They all had matching blue eyes and blond hair. The oldest daughter sat on her Mom's lap and looked ghastly pale. The apprehension in the room was palpable and I tried my hardest to establish good rapport and to build their confidence in me. I asked the patient about school, her favorite things to do and her friends. I talked to her and her little sister about their Halloween costumes. Then I started asking about her symptoms and how she ended up in the Heme/Onc ward late at night. The symptoms had been present for several months and were all very non-specific: persistent cough not relieved with albuterol and singulair, increasingly tired, strange skin discoloration on the chest and neck, cervical lymphadenopathy. In short the Mom told me she "just wasn't the same".

I was thinking of possible reasons this girl could be here and why her family doctor would want an Oncologist to evaluate her. I thought of ALL (acute lymphoblastic leukemia) which is the most common childhood cancer. I started thinking of some of the complaints associated with this disorder (all of which she had already described). I asked about fever and bruising and other things. I then asked about bone pain and Mom's hand flew to her mouth and she said, "Oh my gosh!! Yes! I had totally forgotten about that. She was complaining about hip pain and leg pain". The Mom started tearing up and she started to lose the composure she had maintained up to this point. And guess who else started tearing up and developing a shaky voice and had to pause in order to continue?!? ME!! My emotions swept over me and I nearly started crying along with this mom who was trying so hard to hold it all together. When I started the exam she had to get up and go into the bathroom to compose herself. When I finished, the attending was outside waiting for me and we talked a great deal about ALL and how this very well could be cancer. We ordered a number of different labs and had to wait until morning to find out what was going on.

I left this family thinking for sure their daughter was going to die. Can you even imagine your Doctor crying when you explain the symptoms you have been having. Hello Kent?!? Can you even imagine how scared and how little hope this family had after I left the room. I tried my best to help them not imagine the worst and to explain some of the other possibilities. The attending talked to them about some of the other possibilities. I'm sure it was the stupid med student crying that stuck in their minds that night - not anything we tried to comfort them with later. So did she end up with ALL and a chemotherapy protocol put into place? No! She had Iron deficiency anemia. She was started on iron and had a nutrition consult. simple. easy. case closed. I was pulled in so many different directions the next morning I didn't get a chance to see her before her doctor discharged her. I'm sure they still think I think she has cancer. Grrr... Miller emotions are not going to be the best thing to have as a doctor.

10/10/10

I got an extended weekend thanks to Columbus Day; the base clinics are all closed! Leisy made sure to make my Birthday weekend extra special. We had a blast and it was a party everyday I was home. I was entirely spoiled and it was a lot of fun. It's no wonder Ike and Zeb love when I come home.




Thanks for making my Birthday perfect, Leisy! I love you so much!

Yesterday morning one of the Pediatricians took a small group of us to the animal lab on base. They taught us how to insert chest tubes and intubate babies. In order to practice these skills we put chest tubes in cute, fluffy bunnies and stuck tubes down the ferret's airways. Yes, the animals were as cute as the pictures I found online. Keep in mind that I worked as the animal Nazi for several months and killed countless numbers of animals. I now kill with no remorse. The poor rabbit had a chest tube placed on either side. We were to introduce air into his pleural space which created a pneumothorax. We observed the physiological change and then tried to evacuate the air. The animal was anesthetized and was lying comfortably on the table. When the lung was collapsed it became tachypneic, tachycardic and had prominent nasal flaring. The intern went first and I followed on the other side. I think the rabbit had expired before I even made my first incision. So much for saving the rabbit and nursing it back to health after the procedure!! The ferrets were also sedated and after several intubations may have nasty sore throats but should continue to live happy ferret lives in their quaint ferret habitat. I will see you again next year little ferret.

Dayton!!

My first week in Dayton is almost complete. I have a longer lunch break today so I thought I would update my blogitty-blog. I have been at Wright-Patterson Air Force Base in Dayton, Ohio for the past week. My two week "easy" rotation in Anatomy in Toledo went WAY too fast. The smells and sounds of working on dead bodies reminded me why I was so excited when I successfully completed Anatomy during first year. I was glad to be done, but I was also glad to have a light rotation and spend a lot of time with Leisy, Zeb and Ike. Our Animal Safari adventure was ridiculously memorable. This is the Hospital on base. The pediatric department has all of its clinics for general pediatrics and for specialty pediatrics in one location. They also have child psych and a peds immunization clinic in the same location. Unlike my rotation in Texas, this hospital does not have inpatient pediatrics. All of that is done at a "civilian" hospital in Dayton not too far away from base. Dayton Children's hospital is a beautiful children's hospital where any patient from the base who needs to be admitted will stay. My training would consist of time at the military base and time in the civilian hospital. To me, this is a great advantage to get the "best of both worlds" during my training.

So far I have loved every thing about this program. The staff are approachable, easy to work with and seem to have a great work dynamic. The residents seem to be a part of one big cohesive team. I love the area - Dayton seems to have surprises hidden around every corner. At night I venture out around base and have done a fair bit of exploring. I get excited every time I see a new Metropark, shopping center or restaurant. They have a Cheesecake Factory!!! Traffic is not bad, and the neighborhoods seem pleasant. Dayton has a lot of trees and they are all changing right now. I LOVE Ohio in the fall. The air is crisp, autumn smells are everywhere, I need a jacket when I go outside. What could be better?? Getting accepted to this program and having my family here with me - that's what could be better.

I have constant butterflies in my stomach. I want to come to this program so badly and really these four weeks are a time to prove myself to the program. I'm constantly on edge trying to impress and seem interested and engaged 100% of the time. I also try to play off that I'm nervous about getting in. I try to be interesting and seem like a team player. I know that I just need to relax and be myself - I'm trying to do that, I just want to make sure I'm being my BEST self ALL of the time. (The woes of a hopeful resident).

I have been working in the pediatric clinics and spent all of yesterday in the nursery. I watched some circumcisions and also participated in a C-section and new born examination. Today I worked with the developmental pediatrician which specialty I knew little about. It is a really cool specialty and combines some interesting aspects of pediatrics (psych, genetics, general peds, social and physical development). They have me rotating through many different things to help me get a broad view of the program. I'm looking forward to working with the Cardiologist, GI doctor, and the Adolescent specialist. I'll spend some time in the NICU, PICU and inpatient units at Dayton children's.

Upgrade

Minutes before boarding the plane in Texas, my name was announced over the overhead speakers. "That's strange", I thought. I made my way to the boarding gate and they smiled and asked to exchange my boarding pass for a new one - a first class ticket. What?!? I immediately thought of officer training and being warned to NEVER fly first class in uniform. It just looks bad to have military members acting pretentious on the government's dime. I politely refused and told them I was in uniform. They insisted and said it was perfectly okay, it was Sept. 11, and they thanked me for my service. In my head I thought, "What service?? I haven't done anything yet!" When they called us to board they asked that all military personnel board first. I boarded the plane with 5 other service members including a full bird colonel who gave me a surprised look when I stopped at my first class seat. After he walked to the back of the plane I suggested to the stewardess that maybe the colonel should have my seat. She told me to sit down and relax. "You were probably nicer at the gate than he was", she hypothesized. I felt ridiculously guilty when I stretched my legs out, reclined my seat and washed my face with a heated towel. I continued to feel guilty when I declined wine with my gourmet lunch and guiltier still when they brought out freshly baked cookies. It was the best flight I have had in my life. Maybe I earned it since I was away from my family for 28 days. However, all of my class mates are gone for the same amount of time and they have to pay for everything themselves. So really I didn't earn anything. Maybe someday when I'm deployed and away from my family I will think back to that flight and say - now I've earned it!!

Tropical Storm

"Tropical Storm Hermine gave a wet and windy punch to Texas today. Although the storm hammered Houston and San Antonio today, it's expected to weaken to a Tropical Depression overnight."

The storm was fairly intense. I was in the hospital all day long, but the wind and rain sounded crazy. When it was time to catch the shuttle home it picked us up 10 minutes late. A few sections of freeway were shut down because there was so much water on the road. By that time the rain had slowed to a drizzle. It was still suffocatingly hot and humid, but there were plenty of people in jackets and sweat shirts. Come on(!!) people of San Antonio - a few degrees drop in temperature with rain does not warrant the use of a sweat shirt. It was still ridiculously humid and warm. Hermine - do what you will with Texas for the next few days. Just let me go home in peace on Saturday!!!

Have a mentioned how much a love Pediatrics?!? I'm so excited to know what I want to do for the rest of my life; it's crazy how close I am to being an actual Doctor. This time next year I will have my very own patients and I will be responsible for their care. This week we had a 3 year old with Kawasaki disease. I was so excited because this is something that I swear pops up on every single pediatric test I have yet encountered. It can be fatal if misdiagnosed and even with treatment can have severe consequences. Only early recognition and early treatment has shown to reduce the long-term sequelae. So this little kiddo had the classic presentation: 5 days of fever, conjunctivits, big swollen and cracked lips, strawberry tounge, polymorophous rash on his trunk and extremities, edema of the extremities and lymphadenopathy. He looked miserable but was the sweetest little kid ever. 48 hours later with IVIG and high dose aspirin the kid looks so much better. I spent some time playing Toy Story dominoes with him this afternoon. His mom asked me to write my name on the white board because she wanted to remember "the good things that happened during this horrible experience. You are one of the good things". She just had a baby three weeks ago and her husband left for the weekend after she insisted she would be fine. I'm glad that I was able to help make her miserable week a little better. He had a cardiology consult because Kawasaki can mess up your heart vessels. He had only minor changes that should resolve but they will follow him closely.

Free things in SA

"Here's to the Heroes"

For my last Saturday in San Antonio, I decided to save the biggest "free thing to do" for last:

Sea World!!

As an active duty military member, I can get myself and three other guests into Sea World free once a year. Too bad I didn't have my family with me today. We would have all gotten in!

I saw a lot of animals, made myself sick on some roller coasters, and watched Shamu the Killer Whale show. It would have been so much more fun with my family - but I still had to go check it out. It was FREE!

Congratulations Leisy!! Leisy ran her second "official" half-marathon and scored a personal best! She also got a plaque for fisnishing in the top three of her age division. I'm amazed that she finds the time to put in so many miles to prepare for things like this and can still keep two crazy kids healthy and happy. I love Leisy!! I wish I could have seen her cross the finish line. Great job жена!!

30 hours later...

I am now working in the hospital on the Pediatric floor. We have been super busy and yesterday completely filled the unit. 16 beds were full and our two over flow beds were filled as well. The attending physician stayed way late to help discharge two patients to free up some beds. I was on call last night and helped fill those two vacancies. We were busy with a full unit and then got called to the ER around 1AM to see a patient. This little girl was swollen everywhere, had really bad edema and needed to be admitted. We often get tested about Minimal Change Disorder and I finally got to see it first hand! We had another girl roll in around 3AM and her admission consumed the rest of the morning!

I get on the shuttle at 5:30AM to make it to morning check out around 6AM
See patients and then have morning report at 7:30
Round on patients until lunch
In the afternoon we check up on patients (and I had an interview with one of the program directors)
Check out to the night shift at 5:00
I stayed on with the night shift - was kept busy all night.
Quick cat nap from 4:30 - 5:30 - had time to prepare for morning check out
Morning report at 7:30
Round on patients until lunch (luckily we ended a little early around 10:45)

I was then allowed to go home to sleep. I slept for 4 hours and forced myself to get up so I would still be tired to sleep tonight! Being on call is rough!

I got my Step 2 score back!!! It's the last graded exam of medical school!! I'm happy with my score and I'm done with tests for the rest of the year!!!!! WAHOOOOOOOOOOOOOOOO!!!

Halfway!!

I have reached the halfway point on my San Antonio journey. 2 weeks down! 2 weeks to go! I learned a lot working in the clinic these past two weeks. I saw a number of different things, got a lot of experience with sport's physicals and hopefully made a good impression. I learned a lot, but most importantly realized that I love working in the pediatric clinic as much as I remembered from last year. Now it's on to the wards - I will be working in the hospital on the pediatric ward for the last 2 weeks. I'll be up before the sun everyday for the next two weeks.

It's not really fair that once the weekend arrives I'm totally commitment free and can do as I please. Not fair because Leisy is stuck at home with two demanding children that won't leave her alone for 2 minutes. Not fair because I don't have children to wake me up at night. It's just not fair. I wish I could fly home every Friday night and give Leisy a reprieve from Motherhood. She is doing a fabulous job and I can't imagine anyone who would do better without a husband for weeks and weeks.

This Saturday I went and saw the world's largest pair of cowboy boots. These puppies are 40 feet tall and 35 feet wide. Their official name is "Giant Justins" and were built in 1970. I was trying to get a good shot with me and the boots, but becuase they are so big I was having a hard time capturing the shot. Some nice people took pity on me, pulled their truck to the curb to jump out and snap this pic. (Leisy would have been mortified!!)

I also went to the McNay Art Museum. It is a beautiful mansion that has been converted into a museum. The grounds are vast and have fountains and all sorts of sculptures. The back of the mansion is an extension of the museum. It has a lot of really cool art including some Monet, Picasso, O'Keeffe and other big names. There is also a lot of funky modern art like the exploded tire below. I loved walking through the house and the inner courtyard. This place also charges $8 a person and might be worth it, but I got in free because I am active duty military!!

Sorry Leisy that I can't jump on a plane and come home on the weekends. It doesn't make it any easier for me to be gone when I get to go do fun things without you. Really this weekend was boring and I would much rather be at home with you!!

A few self portraits

I got a package!! It really feels like I'm on a mission when I get a package full of goodies! Not only that, it took about a week to get here. Who would have thought the mail would take so long to get to me on base. Thank you Mom and Family!! I stuffed myself full of pistachios!!

In my attempt to see as much as San Antonio for free, I paid a visit to the San Antonio Museum of Art. It's a big museum and fairly close to the Alamo. They charge eight dollars to get in ($8?!?!) but Tuesday evenings are FREE!! I would only have to pay $5 with my military discount - but $5 is too much for this museum if you ask me. On the fourth floor they have a walkway that gives a nice panoramic view of San Antonio.
I only have 2 more days of the pediatric clinic. I still really enjoy the clinic. Most people either hate it or love it. I start working on Inpatient Peds at the Army base next week. I have really enjoyed the hospital being 2 minutes from my bedroom. Now I have to catch a 30 minute shuttle to work in the mornings. blech...

Mormon Mafia

I first heard of the existence of the so-called "mormon mafia" when I was applying to med school. Interviewing can get really expensive, with airfare, hotels and rental cars. If you can connect with someone in the church they can save you a lot of money and provide you with valuable info. Like when I interviewed in Toledo - I had a ride from the airport, a place to stay (thank you Andrew!) and was immediately put in contact with several other mormon med students (including one on the admissions committee) who could share experiences and what they liked or disliked about the program. Once I was accepted to med school, I became a part of the "mormon mafia" and helped similarly strapped-for-cash interviewees.

I discovered today at church that the "mormon mafia" is even bigger in the military. As soon as I walked into the chapel I was greeted by a member of the bishopric. He found out why I was here and he introduced me to one of the pathology residents, who introduced me to one of the pediatric residents, who introduced me to a pediatrician who just graduated from the program I'm interested in, who also knows the program director of said program who just happens to be the Bishop in his ward. (phew... follow all that?) My phone was soon full of new contacts with e-mail addresses, telephone and pager numbers. All these people were more than willing to answer any questions I had and made sure I could contact them if I had any more.

It looks like I choose a good ward to attend on the first Sunday here. It is full of young families in the military. Most of the residents from Wilford Hall attend this ward. They welcomed me and all asked about my wife home alone with two toddlers. Many of the wives here can empathize with Leisy being all by herself right now. It's hard! Especially on Sundays. Love you and miss you жена моя.

The Alamo!!

For my day off today I explored some of historic San Antonio. I made my way into downtown starting at the Alamo. (I, like Pee-wee Herman, was devastated to discover the Alamo has no basement!). I refused to pay $10 for parking so drove a few blocks away to find free parking. I had one hour to tour the Alamo and part of the River Walk. I moved fast and kept thinking of my parents trailing behind me when we were touring Brazil. It's a good thing they weren't with me today because there was no way I was paying for a taxi! ;)

I then drove to the other four Spanish Missions: San Jose, San Juan, Concepcion and Espada. I made it to all of them without GPS. I'm not sure if my in-laws would believe I didn't get lost once - but I did fairly well. I'm directionally challenged so exploring new places is good for me. Maybe it's Leisy's giggling that distracts me and when I get lost she giggles even more. It's a downward spiral. Downtown San Antonio is a busy place. It looks like there is a lot of fun to be had, and a lot of money to be spent. I'm determined to see as much of it and spend as little as possible. I don't like spending money all by myself.

Info on the Five Spanish Missions

Check out the rest of my pictures on facebook.

Back to School!

School starts on Monday for most of the kids around here. That means we did a lot of back to school physicals in the clinic today. They had the whole clinic set up this afternoon with various stations to get things checked off before seeing the doctor. The hallways had footsteps leading to each station (vitals, immunizations, vision screening, etc.) It was really fun to sit and chat with the teens going back to school and find out what sports they were involved in and what they were most looking forward to. It's nice that they give me 30 minutes with every patient! I can actually get them to open up. One 17-year-old after his visit was over said to my attending, "Are there comment cards anywhere, 'cause this guy is da'bomb!" It kind of made my day.

I have the whole weekend off. I hope to explore San Antonio and find some cool stuff to do. I found a site that had a list of all the free things to do while in San Antonio. I may be going to Catholic Mass if time allows!! One week down. I'm sure it felt much longer to Leisy than it did for me. I have stayed busy. Weekends not working away from home make the time drag by. I miss Leisy and my boys!

First full day!

My Day:

Morning report and lecture - 0730 - 0900
Interesting case of a 5-year-old with unilateral facial droop. Stroke? Bell's Palsy? She had a crazy rare inoperable brainstem tumor. Rare and very poor prognosis.

Joined the NICU team rounds - 0900 - 1130
Quadruplets were among the little ones we rounded on this morning. All have feeding issues and are fed with a tube that goes into their stomachs. They are going to let them try to feed on their own soon. The little tiny ones are so fragile. It seems like a different world in the NICU.

Lunch
In keeping with local customs I decided to try these cup fruits that were all the rage. A nurse came and asked us for orders. The attending was almost jumping up and down he was so excited. An assortment of fruit with lime juice and chili "spices". Interesting. When my fruit cup arrived it looked strange enough to be good. I nearly threw up a few times with the first bite. Not what I was expecting. It somehow robbed the fruit of it's sweetness and left a nasty, spicy aftertaste in my mouth. But I kept eating... Nothing better than a bowl full of fruit. I just pretended the spices weren't there.

Afternoon peds clinic 1245 - 1600
I had my own office with a computer and a patient bed. It was awesome. I would go out to the waiting room and call the patient back. The nurses had already triaged and got vital signs. I have 30 minutes with the patient before I present to the attending. Then the attending comes in and we see the patient together. I love working with kids. I love teaching parents about their children's illness or development. I'm so excited to be a pediatrician. Now I just need to learn how to be a good one!

Exploring, workout and studying 1600 - 2100
I got off base tonight and explored a little more. This is a such a different place. It's unlike anywhere I have ever been. I'm excited to get into down town and explore some more. San Antonio is huge. I love having free membership to a gym. Such a stress reliever at the end of the day! Time to hit the books.

The Lone Star State

Howdy from the great big, hot state of Texas!!

It was so hard to leave my family on Sunday! I had to choke back the tears as I waved goodbye to Leisy, Zeb and Ike from the window of my airplane. I was in full uniform and I didn't want everyone to think I was leaving to Iraq for several months. I'll only be gone for 28 days! However, with only three behind me 28 seems like an awful long time.

I was so nervous about putting my uniform back on. What if I wasn't wearing it properly? What if I forget to salute someone? What if I get yelled at for not doing something properly??? But once several people in the airport thanked me for my service I remembered how much this uniform represents and how lucky I am to wear it. People stepped out of line to shake my hand, or to tell me good job, or just to tell me how beautiful my family is. Tonight after a busy day of running around trying to get proper computer access and security clearances for both hospitals, I stepped out of my car just as the National Anthem started. I stood at attention and saluted all alone in the parking lot. A sense of pride filled me, and I realized again what an honor it is to wear a uniform that represents the courage and bravery of so many Americans.

I'll be rotating in general peds and pediatric infectious disease while I'm down here. The San Antonio program is a combined Army/Air Force program. I will spend half of the time at Wilford Hall Medical Center and the other half at Brooke Army Medical Center. The docs I will be working with are all really cool. I met most of the pediatric team this morning at morning report. One of the infectious disease docs is Mormon! He seems really cool but will be leaving to Haiti next week so I won't get to work with him. (If I stay in the Air Force long enough I may be able to go on several mission trips like he has!!) I am anxious to actually get started now that I have been here doing nothing but busy work. I'll spend tomorrow morning in the NICU and the afternoon in the peds clinic.

WHMC (Left) BAMC (Right)

The heat is super intense. Everyday is over 100 degrees. I'm not sure if Leisy could live here during the summer. She may need to take extended vacations if I end up here!! Yikes!! San Antonio does seem really cool and has a lot of fun things to do for visitors! I'll go check out the sites this weekend. The Alamo, the famous river walk, Sea World maybe??? Anybody been to San Antonio and can suggest cool things to see?

A 66 yo white female presented to the urgent care with 10 days of of increasing pruritus (itchy skin all over), yellowing skin and white part's of eyes, and pale stool. She is admitted to the hospital because of jaundice. The patient has felt fine and her only complaint is being itchy. She has no past medical history and has never been hospitalized in the past. She has never had any history of gallstones, hepatitis or cirrhosis. She had never smoked and rarely drinks alcohol. Physical exam is essentially normal except for discoloration of skin and scleral icterus. She had no abdominal pain on exam. She had tons of labs done but I'm just including LFT's:

	Results	Units	Reference Range
		TOTAL BILI	7.2 H	mg/dL	.2-1.2
		DIRECT BILI	4.8 H	mg/dL	.0-.3
		ALBUMIN	3.1	g/dL	3.1-4.7
		ALKALINE PHOSPH	816 HH	IU/L	40-125
		ALT (SGPT)	305 HH	IU/L	4-42
		AST (SGOT)	257 H	IU/L	10-39
		TOTAL PROTEIN	7.3	g/dL	6.0-8.0

Which of the following diagnoses is most probable and which, if present, has the worst/best prognosis?
A. Choledocholithiasis
B. Pancreatic cancer
C. Klatskin tumor
D. Liver cirrhosis due to a combination of hep B and C
E. Gallbladder cancer

Amazing!!

Toledo Dr. will take team to Haiti for help

Dr. Paat is one of the amazing doctors I have had the chance to work with out here in Ohio. He is such an incredible person and a great physician. He is a great example to me. I wish I could drop everything and head to Haiti right now!! ($20,000 just lying around wouldn't be bad either). Click the link and watch the news report. He is an awesome guy.

My pediatrics rotation ended before Christmas break and I already miss working with little kids! I'm now on Internal Medicine for the next three months. My first 2 weeks of outpatient clinic have flown by. Time is marching steadily on and I am freaking out trying to get all of my military rotations scheduled and lined up for this fall. I'm trying to get everything squared away before I start working in the hospital in February. I'm going to be working longer hours and won't have extra time to work on scheduling rotations.

I have been working in a general internal medicine clinic, an infectious disease and nephrology clinic. One of the biggest signs that I was no longer working in Pediatrics was the difference in "prizes" people get at the doctor's office. Little kids get to look through baskets of toys and stickers after they see the doctor. Some age groups actually get books after they have seen the doctor! I loved finding out what the kid's favorite cartoons were while I examined them so I could hand select the books! Adults in the infectious disease clinic get baskets full of condoms to look through. They are just sitting on the table in a little basket identical to the baskets that used to be full of stickers! They're just hanging out in all of their crazy varieties: all sorts of flavors, glow in the dark, his'n'her pleasure and MEGA!! At least in adolescent medicine they were discreetly hidden in a jack'o lantern trick or treating bucket.

Another major difference between pediatrics and adult medicine has been dealing with patient's apathy about their health. Most little kids want to get better, and if they don't their parents sure would like them to. Adults, after some predetermined age, no longer care about their health. Taking care of one's health just seems to be too big of an inconvience after some mysterious time. I saw a guy with end-stage kidney disease, COPD, high blood pressure, elevated cholesterol, congestive heart failure, depression and a myriad of other problems. We were meeting with him to discuss why he couldn't breathe at night when he lays down to go to bed. He wanted that fixed but seemed irritated when he was reminded that he has been delaying kidney dialysis, gained 20 pounds since his last visit, and wasn't taking his medications like he should!! I need to discover a new perspective during this rotation. How am I going to find the desire to help those who aren't willing to help themselves??